Pregnancy is a time when the mother undergoes many physical and physiological changes. These changes happen so that the mother’s womb can nurture and host the growing baby. However, there are other possible effects of these changes on the musculoskeletal, cardiovascular and respiratory system of the expectant mother. Therefore, it is important to be aware of these effects in order to help the expectant mother to cope with the challenges of pregnancy.

What are the effects of the hormonal and Physiological changes during pregnancy?

Hormonal changes: Progesterone and Relaxin are two hormones whose levels are extraordinarily high during pregnancy.

They cause changes in the collagen fibres of the connective tissues of the joints and soft tissue structures.

Loosening of ligaments decreases the stability of the joints.

Weight gain: Excessive weight and gravity can slow down the circulation of blood and body fluids mainly in the lower limbs.

This can cause excessive workload on the body with physical activity

Excessive fluid retention

Swelling in the limbs and even face.

Postural change:

Fig 1: Improper postures and good posture

Improper postures as shown in Fig 1, due to increased weight gain and forward shift of the centre of gravity. It can also affect balance and gait.

Improper postures:

increased lower back curvature – lumbar lordosis,

compensatory curving of the upper back – kyphosis or scoliosis,

rounding of shoulders

forward chin position

Muscular changes: As the baby grows the mother’s abdominal muscles and ligaments get stretched.

Weakness of the abdominal muscle

Less support or bracing to the spine

Due to weight gain, improper posture and possibly lack of gait control, there will be an excessive strain to the muscles of the hips, knees and ankles.

Blood Pressure changes: Pregnancy hormones can suddenly affect the blood vessels by narrowing or expanding them, causing a drop or sudden increase in blood pressure. This if may affect the blood supply to the vital organs like the brain and in severe cases may also affect the growing baby.

Low blood pressure may cause:

Dizziness

Brief loss of consciousness (passing out)

High blood pressure in pregnancy is also known as pre-eclampsia which may worsen to a condition called eclampsia.

Symptoms of Eclampsia:

Severe headaches and convulsions.

Problems with your vision, such as blurred vision, flashing lights or spots in front of your eyes.

Tummy (abdominal) pain, vomiting later in your pregnancy (not the morning sickness of early pregnancy).

Sudden swelling or puffiness of your hands, face or feet.

Changes in the Respiratory system: As the uterus enlarges, the movement of the diaphragm (main breathing muscle) may be limited. The uterus moves upwards, it progressively obstructs the downward movement of the diaphragm as shown in fig 2.

Fig 2: Uterus and abdominal contents pushing the diaphragm

It can force the diaphragm upwards mostly towards the end stage of pregnancy causing:

Breathlessness: difficulting in breathing normally.

Painful ribs: Rising pressure pushes the rib cage out sideways and forwards, resulting in pain in the front of the lower ribs, also known as rib flare.

Increased Metabolic Rate: Basal or resting metabolic rate (RMR) is the amount of energy the body uses while at rest. Due to hormonal changes, this RMR increases significantly during pregnancy that may put the pregnant women at a higher risk of developing hypoglycemia or low blood sugar leading to light-headedness and fainting.

Risk of health conditions during Pregnancy

Ligament and joint sprain: As the ligaments are lax due to hormonal changes, there is more risk of ligament and joint sprains especially in the ankle joint during pregnancy. Ligaments of the feet become lax and with the additional weight of pregnancy, results in flat feet and development of painful conditions like plantar fasciitis, Achilles tendonitis etc.

Painful joints: Incorrect posture causes abnormal curves like kyphoscoliosis and scoliosis which may cause issues for anesthesia during pregnancy and delivery. They also exert excessive strain and fatigue on the body, particularly in the spine, pelvis and other weight-bearing joints (i.e. knees). This results in aches and pains, such as lower back, with the pain spreading to the buttocks, thighs and down the legs.

Low back Pain: The extra weight of the baby coupled with the shift in weight distribution may strain the back muscles and can cause muscular spasms. Excessive pressure placed on the back may also cause low back disc herniation that may affect the spinal nerves.

Posterior pelvic pain (PPP): Lax ligaments of the body allows the pelvis to enlarge, in preparation for childbirth. Also, due to the growing uterus, some of the core muscles around the pelvis get ‘stretched’ and weakened. This affects the stability of the sacroiliac (SI) joints – the joints between the tail bone and the pelvic bones on either side at the lower back region as shown in Fig 2.

Fig 2: Sacroiliac joint

Diastasis recti: “Diastasis” means separation. “Recti” refers to your abdominal muscle called the “rectus abdominis.” The rectus abdominis muscle runs in the front of the stomach and is excessively stretched during pregnancy. Sometimes the pressure increase due to baby growth may be too much causing the muscle to separate as shown in Fig 3.

Fig 3: Separation of Rectus abdominis muscle.

This separation in the abdominal muscles may lead to:

Low back pain: due to lack of bracing to the spine.

Hernia: a condition when the abdominal contents can protrude out due to increasing pressure from growing baby and lack of support by the abdominal muscles. Umbilical hernia as shown in Fig 3.

Fig 3: Umbilical hernia

Pubic symphysis pain: The weight-bearing joints, such as the pelvis, is increasingly stressed and loaded during pregnancy. Coupled with the instability that relaxin causes, the pelvis is susceptible to pain and injury. Sometimes due to stress, the pubic symphysis may be separated causing a condition known as symphysis pubis diastasis as shown in Fig 4. This commonly occurs during delivery.

Fig 4: Symphysis Pubis Diastasis

Transient osteoporosis: This is a bone condition that happens during pregnancy and symptoms disappear within weeks of labour. It has no known cause, although hormones, nutrient deficiency, and other causes have been proposed. There is a sudden drastic loss of bone mass and swelling in the affected portion during pregnancy. This causes weakness of the bones which may lead to fractures during delivery and other complications for the mother.

Gestational Diabetes: Due to hormonal changes in your body, your cells can become less responsive to insulin. When the body needs additional insulin, the pancreas dutifully secretes more of it. However as the cells are unable to respond to it, your blood glucose levels rises too high resulting in gestational diabetes. This may lead to excessive weight gain and development of diabetes post pregnancy.

Carpal tunnel syndrome: “Water retention” or swelling in ankles, feet and hands in late pregnancy may lead to joint stiffness and nerve compression syndromes, such as carpal tunnel syndrome.

Varicose veins: Varicose veins of the legs may occur during pregnancy or worsen during this period. This is due to a reduction in the vascular tone and changes in the collagen structure in the body (due to progesterone and relaxin) that affect the veins.

How to prevent health conditions during pregnancy?

Always monitor your health status and evaluate the presence of any specific health condition at an initial stage.

It is important to understand your body in order to avoid conditions and the potential complications it may cause. Proper treatment planning is undertaken at an early stage to ensure the safety and health of both the expectant mother and the baby.

As most of these conditions can be prevented with lifestyle and dietary changes, it is best to consult with the experts to know more in details about how to manage and prevent them.

Restless legs syndrome (RLS) is a neurological disorder that is characterized by an uncomfortable sensation in the legs and rarely the arms. This leads to an overwhelming urge to move them continuously.

These movements may,

happen to partially or totally relieve discomfort.

begin or worsen during periods of rest such as lying or sitting

worsen during sleep, causes time to time movements also known as “periodic leg movements”.

It has also been suggested that RLS would be called “Willis-Ekbom disease”, as an homage to the two pioneers Thomas Willis and Karl-Axel Ekbom who first reported this condition.

What causes RLS?

Unknown cause

Genetic cause

RLS symptoms are related to hyperexcitability of the central nervous system- brain and spinal cord due to a possible deficiency of a chemical called dopamine. Dopamine plays a role in controlling muscle movement and may be responsible for the involuntary leg movements associated with RLS.

Disorder of the peripheral nervous system

The peripheral nervous system involves the nerves that carry signals from different parts of the body to the brain. The most likely possibility is the presence of hypoxia (lack of oxygen) caused by changes in blood flow or metabolism in the lower limbs that irritates the sensory nerves of the legs causing restlessness.

Iron-deficiency anaemia – low levels of iron in the blood can lead to a drop in dopamine, triggering restless legs syndrome

Radiculopathies: Radiculopathies are problems with the nerves and occur due to nerve compression at the spine caused by disc herniation and protrusion and/or disc degeneration. It is most commonly seen in the lower back regions (Lumbar spine). Nerve compression could cause referred pain and tingling sensations along the back of the leg to the feet that may be a secondary cause for RLS.

Pregnancy – particularly from week 27 until birth; in most cases, the symptoms disappear within four weeks of giving birth

Side effects of certain medication: Antidepressants, Antipsychotic medicine, Lithium (used in the treatment of bipolar disorder), Calcium channel blockers (used in the treatment of high blood pressure), Antihistamines, Metoclopramide (used to relieve nausea).

Both the genders are affected but women are twice as likely to develop RLS than men which is still unknown and is suggested to be related to genetics, body functions or emotional differences.

People of all ages can be affected but more commonly seen among middle-aged people secondary to other health conditions.

What are the signs and symptoms of RLS?

Signs and symptoms may vary from day to day, in severity and frequency from person to person during rest and most often during sleep.

Abnormal sensations (Paresthesias)- pulling, creeping etc.

Unpleasant abnormal sensations (Dysesthesias)- the sensations range in severity from uncomfortable to irritating to painful example, tingling, burning, aching or like electric shocks.

Periodic leg movements during sleep

Typical movements like pacing and walking, jiggling the legs, stretching and bending, tossing and turning, rubbing the legs.

Inability to sleep leading to sleep disorders like insomnia (lack of sleep) due to increased urge to move or sudden waking up from sleep due to periodic leg movements.

Hyperactivity may be seen among children with RLS.

Fatigue/tiredness, lack of concentration, problems with cognitive function (related to thinking, attention and decision making) due to lack of sleep and excessive movements in the leg most often felt throughout the day.

How is RLS diagnosed?

There are no diagnostic tests that can diagnose RLS.

A thorough clinical assessment of the patient is necessary to be able to diagnose this condition.

Clinical history: The history of the patient about signs and symptoms associated with RLS will be important for the diagnosis. The frequency, duration, and intensity of symptoms the aggravating and relieving factors as well as their tendency to occur during day and night time will be noted.

Family and Medical History: Family history and problems of other health conditions and the use of medications will be noted that may be the suggestive cause for RLS.

Neurological and physical examination: Examination of other underlying conditions related to muscle or nerve problems.

Blood tests: blood test can be done to identify iron and vitamin deficiencies as well as other medical disorders associated with RLS.

Sleep studies such as polysomnography (a test that records the individual’s brain waves, heartbeat, breathing, and leg movements during an entire night of sleep) may identify the presence of periodic leg movements and other problems of sleep.

RLS in children: This may be difficult since it may be hard for a child to describe any uncomfortable sensations in the leg and the urge for leg movements, when and how often the symptoms occur, and how long they last.

Misdiagnosis: RLS may be often misdiagnosed as “growing pains” or “Attention Deficit Hyperactivity disorder” (ADHD) in children and may be mistaken to be an onset of another neurological disease, such as Parkinson’s disease in adults.

How can this condition be treated?

Most symptoms can be treated by therapeutic treatments that improve the blood circulation of the legs, muscle flexibility and allow the nerves of the legs to relax. This can help diminish the uncomfortable sensations caused by restless legs syndrome.

Identification and treatment of other health problems are important to reduce the symptoms of RLS.

Intake of diet rich in iron and vitamins will be beneficial.

Reducing smoking and alcohol consumption.

Stress management will help reduce symptoms and improve sleep.

Severe problems with RLS can be also be treated along with prescribed medications that improve the dopamine levels in the body. However, RLS may generally be a lifelong condition.There may be periods of no symptoms but may eventually reappear sooner or later. Adhering to the treatment methods can help reduce the symptoms at all times.

The thickest and the strongest tendon in our body is the tendon of the calf muscles of the leg also known as the “Achilles tendon”.

Fig 1: Calf muscles and Achilles tendon

As shown in Fig 1, the calf muscles of the leg include the gastrocnemius and the soleus muscles that tapers and merges with a tough connective tissue of the Achilles’ tendon. The Achilles tendon then inserts into the heel bone (calcaneus). Functions of the Achilles Tendon

Downward Movement of the foot: When the calf muscles contracts and pulls the Achilles tendon it causes the foot to push downward. This contraction enables: gait, standing on the toes, running, and jumping.

Bending the knee: The gastrocnemius muscle helps in bending the knee (flexion) during walking and running.

Transferring body weight: With each step of walking each of the Achilles tendon help to distribute the person’s body weight. Depending upon the speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subjected to approximately 3-12 times a person’s body weight.

Ankle stability: Along with the other muscles of the leg the Achilles tendon contributes to the stability of the ankle joint.

What surrounds the Achilles tendon?The Achilles tendon is protected by the Achilles tendon sheath and bursae. The sheath is the covering of the tendon that protects the tendon from friction and allows smooth movements. Similarly, the bursae around the Achilles is a thin fluid-filled sac that help to reduce friction between tendon and other tissue areas of the heel.

Fig 2: Bursae around the Achilles tendon

As shown in Fig 2, there are two bursae present at the heel. One of the bursae is present in between the surface of the tendon and the surface of the calcaneus at the distal attachment of the Achilles tendon. It is called the “retrocalcaneal bursa”. The other bursa is present between the calcaneum and the skin and is called as the “subcutaneous calcaneal bursa”.

Brief History on Achilles tendon injuries

Because of the Greek Achilles legend, the Achilles heel is known as a vulnerable part for injury. Hippocrates described that “this tendon if bruised or cut causes the most acute fevers, induces choking, deranges the mind and at length brings death”. It was first reported that a ruptured tendon was to be wrapped with bandages dipped in wine and spices. Since then the cause and treatment of Achilles tendon injuries have brought growing interests among many researchers.

What causes an Achilles tendon injury?

Overuse injuries

This is mostly sports related and is due to overuse of the calf muscles causing an injury to the Achilles tendon. Overdoing or rapid action of the calf muscles or resuming too quickly after a layoff can stress the Achilles tendon. For example, while running or walking faster, up and down on steeper hills or stairs more powerful movements such as lunges, jumps, or push off.

Misalignment and muscle imbalances

Short or tight Achilles tendons or calf muscles, unequal leg length, over or under arched foot, disproportionally weak calf muscles.

Improper Footwear

Side effects of certain medications

Medications (Quinolone / Fluoroquinolone and Cortisone) can weaken the Achilles tendon and this may lead to an injury. Cortisone shots in or near the Achilles tendon may reduce pain in the Achilles tendon, but the weakness in the tendons persists which can an injury during activities.

Accidental trauma

Inflammatory conditions

Achilles injury may occur in relation to inflammatory illnesses, such as ankylosing spondylitis, reactive arthritis, gout or rheumatoid arthritis.

Genetic

Individuals with a genetic predisposition like hypermobile people are reported to be more at risk of developing Achilles tendon problems. This is because they have excessive laxity in ankle joints that lead to the wear and tear of the Achilles tendon.

Achilles tendon injuries

Fig 3. Locations of injury

As shown in Fig 3, different types of Injuries to the tendon can occur along different locations of the tendon.

Musculotendinous junction: This explains the junction between the calf muscle and the Achilles tendon.

Mid portion of the tendon: This explains an injury midway between the top and bottom of the Achilles tendon.

Insertional Achilles tendon injury is an injury at the bottom of the Achilles tendon, where the Achilles tendon connects with (inserts into) the heel bone.

Non-insertional Achilles tendon injury means an injury to any part of the Achilles tendon except at the Achilles tendon – heel bone connection.

Types of Achilles injuries

The spectrum of Achilles injuries ranges from an acute inflammatory irritation to severe cases of rupture of the tendon as shown in Fig 4. The types of condition may co-exist depending on the severity of the injury.

Fig 4: Types of Achilles Tendon Injuries

Tendonitis and tenosynovitis

Achilles tendonitis is an acute inflammation of the Achilles tendon as shown in Fig 5. Tenosynovitis is an inflammatory condition of the Achilles tendon sheath, rather than an inflammation in the Achilles tendon itself.

Fig 5: Achilles Tendonitis

Achilles Tendinosis (Tendinopathy): This is the degeneration and micro tears of the Achilles tendon that occurs over time due to overuse of an already inflamed and weak tendon (Refer Fig 6).

Both Achilles tendonitis and tenosynovitis can occur in parallel with, or lead to Achilles tendinosis.

Fig 6: Tendinosis of Achilles tendon

Tendon Ruptures (Partial or complete tendon tear)Achilles tendon rupture is often described as an abrupt break with instantaneous pain that is felt in the foot or heel area. It occurs rapidly while performing activity like running or standing on the toes, which generates intense force on the tendon, leading to partial or complete rupture as shown in Fig 7.

Fig 7: Complete and partial tear of the Achilles tendon

What can happen if you have an Achilles tendon injury?

Pain and tenderness along the Achilles tendon and at the back of the heel that worsens with activity.

Thickening of the tendon

Bone spur formation at the insert of the tendon

Bruising and Swelling around the tendon area.

Fibrosis and scarring may be seen in Achilles Tenosynovitis and tendinosis.

Restriction of Achilles tendon’s motion within the Achilles tendon sheath.

Bursitis: Inflammation of the bursas around the Achilles tendons.

Snapping or popping noise can indicate a tendon rupture.

Difficulty in moving the foot or pointing your toes (in complete tears of the tendon)

A limp may be seen on weight bearing immediately after an Achilles tendon rupture

How is an Achilles tendon injury diagnosed?An initial examination of the ankle can help differentiate a tendon rupture from other types of injury. When an Achilles tendon rupture occurs, it will not be possible for the individual to stand on toes as shown in Fig 8.

Fig 8: Achilles tendon rupture of the Left heel

An MRI or X-ray investigation can also be taken to further confirm the severity of the injury and differentiate the type of injury to the tendon. For example, an MRI scan of a ruptured Achilles tendon is shown in Fig 9.

Fig 9: Achilles tendon rupture

When to seek expert care?

If you felt a sharp pain like a direct hit to the Achilles tendon or if you heard a distinct snap at your Achilles tendon, it calls for a medical emergency. If you have just begun with pain in the back of heels with swelling or discomfort in the Achilles tendon, it would be wise to seek expert assessment and treatment care. What may seem like a mild inflammation may lead to degeneration and rupture. Thus, an initial treatment for tendonitis will not only reduce problems of the tendon but will restore its strength and function which is important to prevent worsening and recurrence of the condition.

Blood pressure is the pressure exerted by the circulating blood on the walls of the blood vessels.

What system is it part of and why?

BP is a part of the blood circulatory system, which is also known as the cardiovascular system(Refer Fig 1)

The heart

The blood vessels – arteries and veins

Fig 1: The Circulatory System

The heart acts as a pump that is responsible for,

pumping oxygenated blood carried by the arteries to our organs

pumping deoxygenated blood that it receives through the veins from our organs.

One of the functions of the circulatory system is to regulate the blood pressure for maintaining good blood flow throughout the body. This is required in order to transport nutrients and oxygen for every body part, for regulating body temperature, pH balance and for normal functioning of the body.

For example, when the heart pumps out oxygenated blood through the arteries, the blood flow exerts a force on the walls of the arteries. This force is measured as arterial blood pressure as shown in Fig 2. Any problems with this arterial BP may lead to a problem with the normal functioning of the body.

Fig 2: Arterial Blood pressure

How is Arterial BP measured?

The instrument that can measure the blood pressure is called Sphygmomanometer (Refer Fig

Fig 3: Sphygmomanometer

It consists of:

a cuff,

a pump, and

a calibrated mercury scale

Typically two numbers that are being recorded on the scale which is written as a ratio. For example, BP of 120/70 mmHg, where 120 is the top number and 70 is the bottom number.

Fig 3: Measuring BP

As shown in Fig 3, the BP is measured in four steps,

Step 1: Locate the pulse on an artery of the arm

Step 2: The health professional wraps the cuff around your arm and inflates it to squeeze your arm. This is done to temporarily press on the artery and close the blood flow in your arm.

Step 3: After the cuff is inflated, the health professional will slowly let air out. While doing this, he or she will listen to your pulse with a stethoscope and watch the mercury level on the calibrated scale to accurately note the measurements. The first pulse sound is heard and simultaneously measured on the scale.

Step 4: As the successive pulse sounds continue the professional hears it until the last pulse sound is heard which is again measured.

The scale used is in “millimeters of mercury” (mmHg) to measure the pressure in your blood artery.

Blood pressure numbers- what does it indicate?

Fig 4: Systole and Diastole of the heart

The top number- Systolic pressure

The top number, which is also the higher of the two numbers, is the measure of the pressure in the arteries when the heart beats or contracts to pump the oxygenated blood. This is also known as the systole of the heart as shown in fig 4.

The bottom number- Diastolic pressure

The bottom number is also the lower of the two numbers. It indicates the pressure in the arteries when the heart muscles are relaxing between two heart beats and refilling with blood. This is also known as the diastole of the heart as shown in fig 4.

BP Categories

Fig 5: BP Categories

Typically more attention is given to the top number (the systolic blood pressure), however, both the systolic and the diastolic pressures are important for indicating if a person is at risk of any heart disease.

What are the risk factors that will lead to high or low BP?

Risk factors

High BP

Low BP

Family history of High BP

Advanced age

Men get High BP more than women

Sedentary lifestyle

Poor diet, excessive salt intake

Drinking too much alcohol

Obesity

Smoking

Stress

Sleep apnea- a sleep disorder in which tissues in the throat collapse and block the airway.

Prolonged bed rest

Pregnancy

Trauma- loss of blood from major trauma, dehydration or severe internal bleeding

There’s a common misconception that people will experience symptoms such as nervousness, sweating, difficulty sleeping or facial flushing. But the truth is that changes in blood pressure can be a symptomless condition. If you ignore your blood pressure because you think symptoms will alert you to the problem, you are actually taking a risk. It is important to know your blood pressure numbers as everyone should prevent blood pressure problems.

However, there are few signs and symptoms that may possibly occur with low and high BP.

Signs and symptoms

High BP

Low BP

Severe headaches

Severe anxiety

Shortness of breath

Nosebleeds

Blood spots in the eyes

Facial flushing

Dizziness or lightheadedness

Fainting

Dehydration and unusual thirst

Lack of concentration

Blurred vision

Nausea

Cold, clammy, pale skin

Rapid, shallow breathing

Fatigue

Depression

How to manage BP problems?

Routine Check-up: Most people are unaware of their BP problems and going for a check-up will detect any blood pressure problems. This will prevent any potential health conditions.

Understand your normal level of BP: There is no healthy level of high blood pressure or low blood pressure. Your healthcare professional will determine your treatment goals based on your overall lifestyle and your body.

Lifestyle modifications

A nutritional diet, which may include reducing salt depending on High or low BP, Vitamin and mineral rich diet.

Physical activity – exercise

Maintaining a healthy weight

Stress management

Smoking cessation support

Alcohol limitations

Prescribed medication in specific cases

Take precautions while exposed to heat

When your body gets heated up during hot weather or during a hot tub or sauna bath, your blood pressure could drop and your heart rate may increase to counteract a drop in blood pressure. Normally, these events don’t cause problems. However, if you have an existing low BP you may be at risk of fainting, falls and heart problems.

Some of the precautions can be,

Limit your exposure to heat. Most experts say no more than five to 10 minutes is safe.

Stay hydrated.

Regulate water temperature during hot tub or sauna baths.

Conclusion

Managing blood pressure requires an individual’s adherence to the lifestyle changes and habits. It is advisable to get early assessment and treatment of your blood pressure problems in order to have a healthy circulatory system and to prevent the risk of many health conditions.

Many people experience a prompt reddening on their face after few drinks of alcohol. It is called “Alcohol flush reaction” and is also known as “Asian flush syndrome” due to its greater prevalence among Asians. The reaction is often considered to be a sign of natural body protection mechanism from excessive drinking. What might seem like an unexpected natural reaction is, in fact, a sign of alcohol intolerance. An associated risk factor to many health conditions.

Alcohol tolerance vs Intolerance

Alcohol tolerance is the ability of the body to metabolize alcohol and reduce its concentration in the blood. When the body and the brain are subjected to alcohol, it activates the liver to produce large amounts of liver enzymes for the breakdown of alcohol to flush out any toxic products of alcohol out of the body.

Alcohol intolerance is the inability of the liver to break down alcohol. It is related to a genetic disorder of aldehyde dehydrogenase gene (ALD­H2) that is responsible for normal functioning of the liver enzymes. Due to its absence, a toxic by-product of alcohol called ac­etalde­hyde builds up in the blood which causes intolerance.

Acetaldehyde in the blood triggers Alcohol flush reaction. It also releases a chemical called histamine in the body that causes inflammation and aids allergic reaction.

Signs and Symptoms of high levels of blood acetaldehyde

Redness and flushing

One of the earliest reaction of Alcohol flush involves a persistently red face (refer Fig 1) due to enlarged blood vessels. This may also be seen on the chest and neck region.

Fig 1. Alcohol Flush Reaction

Palpitations

Acetaldehyde increases palpitation which is a sensation within the chest that brings awareness of an irregular or racing heartbeats.

Increased heart rate

An increase in heart rate is seen with increased levels of acetaldehyde. It causes the blood vessels to dilate, making the heart pump harder and faster for the blood to flow through relaxed blood vessels.

Low blood pressure

Blood pressure is the pressure of blood in the circulatory system. Due to the alcohol reaction, the heart beats faster pumping out less volume of blood and dropping the blood pressure. One may feel light headed and dizzy which can get severe.

Extreme drowsiness and headaches

The direct cause is unknown, however, it is believed that due to the expansion of the blood vessels in the brain, histamine release and low blood pressure one may get extreme drowsiness and headaches.

Pruritus (Itching)

This is an unpleasant sensation that provokes the desire to itch or scratch. This happens due to irritated nerve endings on the skin caused by histamine released by the acetaldehyde levels in the blood.

Nausea

A feeling of vomiting starts as the acetaldehyde levels in the body irritate the stomach lining, leading to inflammation (gastritis).

Alcohol-induced asthma

Increased levels of acetaldehyde and histamine release in the body can trigger breathlessness due to constriction of the airway. It is often reported to appear after approximately 30 minutes post-alcohol consumption.

Risk Factors associated with people who get Alcohol Flush Reaction

Esophageal Cancer

Acetaldehyde in the blood is known to interfere with the DNA synthesis and repair mechanism and increases the risk of cancer by producing free radicals that are known to destroy healthy cells.

Alzheimer’s disease:

Alzheimer’s disease is a neurological disorder in which the death of brain cells causes memory loss and affects brain function. Research has claimed that genetic disorder related to the aldehyde enzyme also interact with the brain cells which are believed to be a risk factor of Alzheimer’s disease.

Heart disease

Continual drinking of alcohol among people with Alcohol flush reaction will affect the functioning of the heart and may lead to the risk of heart problems.

Liver disease

Acetaldehyde causes oxygen deficits in the liver (hypoxia), including formation of harmful compounds that damage the cells of the liver leading to a liver disease.

Are you sensitive to alcohol or is it something else?

If you are only experiencing this reaction with specific alcohol beverages. This may suggest that it is not alcohol intolerance but could be due to other ingredients involved that triggered the reaction.

What can be done about the Alcohol flush reaction?

There is medication available to help with the flush. However, these drugs can only curb the redness but will not be able to break down the acetaldehyde levels in the body. Thus, individuals who drink often and use drugs to suppress the flushing will still be at risk of developing a health problems.

The best way to prevent alcohol flush reaction and minimise health issues is by not drinking alcohol at all. This may however be an unrealistic solution to many especially during social events.

There are few things one could consider that may help reduce the alcohol flush reaction:

Eating before alcohol consumption.

Having drinks with lower alcohol content.

Alternate alcoholic drinks with water or non-alcoholic drinks.

Like all things, always consume alcohol in moderation. Alcohol is a depressant, but it’s also an indirect stimulant. Never drink and drive. Medication can help mask the reaction but if you feel that it’s more than just a flush, always seek immediate medical attention.

An ankle injury is the most common type of injury that may involve the bones of the ankle and other soft tissue structures. Three are three types of injuries that are observed at the ankle:

Sprains

Strains

Fractures

Sprains are injuries to the ligaments that connect one bone to another. An ankle sprain may involve an injury to one or more ligaments that stabilize the ankle and the foot.

Strains are injuries that involve musculotendinous (muscle and tendon) structures. Both sprains and strains can occur due to over-stretching or tearing of the ligaments and tendons due to sudden twisting of the ankle joint or when excessive forces are applied on them.

Fractures are injuries that involve bones of the ankle joint. It ranges from a simple break in one bone to several fractures, which causes your ankle to move out of place and puts you in great pain.

This is the most common injury to the ankle. Often, an inversion sprain could be an associated with a fracture and a strain to the peroneal tendons.

An inversion sprain happens when the ankle in twisted inwards with an inward rolled foot as shown in Fig 1.

Fig 1: Lateral ankle injury

The Medial ankle injury

This type of injury occurs at the inner aspect of the ankle. Like a inversion sprain, the eversion sprain may also be associated with fractures of lower ends of the leg bones and strains to the tibialis anterior muscle.

Eversion sprain happens when the ankle is twisted out with the foot rolled outwards as shown in Fig 2.

Fig 2: Medial ankle injury

High Ankle Injury

This type of injury is very rare. A high ankle sprain happens when the tibia bone rotates injuring the ligaments that hold the lower end of the two leg bones (tibia and fibula) as shown in Fig 3.

Severe injuries may cause fracture to the lower ends of the leg bones.

Fig 3: High ankle injury

Severity of an ankle sprain

An ankle ligament sprain can be graded according to the severity of the tear in the ligaments as shown in Fig 4.

Fig 4: Grades of ankle sprain

Sign and Symptoms of Ankle Injury

Swelling: Increased fluid in the tissue due to inflammation and soft tissue damage.

Pain: Depending upon the severity of the injury and the structures involved, pain intensity can vary.

Unstable ankle: The affected side feels weak and difficult to weight-bear.

Deformity: Severe injuries can cause fractured bones to move out of place and make the ankle look deformed.

Causes of Ankle Injury

Trauma

Stepping in a hole or a stone

Running on uneven ground

Fall or slippage on wet floor

Contact injury during sports like basketball, when a player is accidentally hit by an opponent causing the foot to roll inwards as shown in Fig 5.

Fig 5: Lateral ankle sprain during basketball

Muscle imbalances

Lack of flexibility in muscles can hamper joint movement. For example, if the calf muscles are very tight, it will affect the stability and mobility of the ankle joint. In such a state, if one engages in any physical activity like running there could be a potential risk of twisting an ankle. Sometimes even lack of warm-up and stretching could be the cause of muscle imbalances.

Lack of Postural control

Postural control is defined as the act of maintaining, achieving or restoring a state of balance during any posture or activity.

It helps to maintain a good base of support for balance so that the force of gravity can act on the center of mass (COM) of the body. Centre of mass is the point in the body where the entire body weight is concentrated (located in the lower end of the spine) as shown in Fig 6.

Fig 6: Line of gravity and base of support

During sports, sudden quick body movements or external forces like a push or a contact by an opponent will affect your balance. If you lack postural controlm you may lose balance and risk hurting your ankle.

Diagnosis of an ankle injury

Most ankle injuries are usually straightforward ligament strains. However, the clinical presentation of subtle fractures can be similar to that of a ankle sprains and these fractures can be easily missed on initial examination. Fractures are usually detected via X-ray scans. If any fracture is left untreated, it may cause excessive pain and disability to an extent that youmay not be able to bear weight on the joint. Therefore, an X-ray or an MRI scan is often recommended to understand the severity of the injury.

For example, a lateral ankle sprain showing fractured bones in an X-ray is shown in fig 7.

Fig 7: Lateral ankle sprain with fracture of the lower end of fibula bone

Ankle Injurymanagement

Usually, ligament injuries heal in about 6-12 weeks and fractured bones take about 3-6 months to heal. This is however largely dependent on the severity of the injury and lifestyle of the individual so complete healing time frame may vary.

Even after the healing process, ankle injuries may cause long term instability if not healed correctly. This may also be the cause of recurrent ankle sprains. An expert assessment of ankle mechanics is very important to decide on how long to protect and rehabilitate an ankle after an injury. The treatment plan will aim to restore the normal functions of the ankle and make return-to-play decisions based on the stability of the ankle thus preventing recurrent ankle injuries.

Like this:

The ankle plays an important role in the pattern of lower limb movements both in weight-bearing and non-weight-bearing positions.

Ankle movements: (Refer Fig 1)

Plantarflexion (down)

Dorsiflexion(up)

Inversion (inwards)

Eversion (outwards)

Fig 1: Dorsiflexion, Plantarflexion, Eversion and Inversion

Plantar flexion is the movement that describes the pointing of the toes toward the ground, as in standing on one’s toes.

Dorsiflexion is the opposite of plantarflexion and involves pulling the toes up as in walking on one’s heels.

Inversion is inward rolling of the foot towards the body’s midline and eversion is the exact opposite which involves outward rolling of the foot away from the midline of the body.

Joints in relation to movement

The ankle is made up of three distinct joints namely,

Talo-crural joint (Ankle joint)

Subtalar joint

Distal Tibiofibular joint (High ankle)

Fig 2: 3 types of ankle joints

Talo-crural joint (Ankle joint): It a hinge type of joint that allows movements of dorsiflexion and plantar flexion along one plane.The articulation of the lower ends of the leg bones and one of the tarsal bones (talus) forms the ankle joint.

Subtalar joint: The movements of Inversion and eversion take place at this joint. It lies beneath the ankle joint and is formed by the articulation between the talus and the calcaneal bone of the foot.

Distal tibiofibular joint (High ankle): This is a syndesmosis joint between the lower ends of the bones of the leg(tibia and fibula). A syndesmosis joint is a joint where the bones are connected by ligaments and have minimal movements.

Muscles that cause ankle movements

The muscles from the leg end as tendons that attach to the foot bones. They contract and transfer forces to cause a movement across the ankle joint.

Outer muscles of the leg: The peroneal (Peroneus long and peroneus brevis) muscles are present on the outside aspect of the leg as shown in Fig 3. The contraction of the peroneal muscles help bend the ankle down moving the foot downwards (Plantar flexion) as in fig 3.

Fig 3: Peroneal Muscles and Plantar flexion

The peroneals also help to stabilize the big toe as it attaches behind it. It helps to lift the arch and plantar fascia to produce spring-like effect during running and jumping activities.

Back muscles of the leg: The calf muscles (gastrocnemius and soleus) and the tibialis posterior muscles are present at the back of the leg as shown in Fig 4.

Fig 4: Calf and Tibialis posterior muscle.

The calf connects to the heel bone by the Achilles’ tendon. When the calf muscles contract they moving the foot downwards (Plantar Flexion). The posterior tibialis help to turn the foot inwards (Inversion). They help to propel the body forwards as the foot pushes on the ground while walking.

Front muscles of the leg: The tibialis anterior present in the front of the leg and attached in the front of the foot as shown in Fig 5.

Fig 5: Tibialis anterior muscle and dorsiflexion

The Tibialis anterior muscle pulls the ankle upwards (Dorsiflexion). It plays a role in striking the heel when you take a step forwards in walking.

Ligaments that support the ankle

Apart from muscles, the ankle is stabilized by many ligaments that surround the ankle.

Lateral ligaments (outer ankle ligaments)

Medial ligaments (inner ankle ligaments)

High ankle ligaments

Lateral ligaments

Lateral ligaments are present on the outer aspect of the ankle that are attached at the anterior (front), lateral (outer side) and posterior (back) parts of the ankle as shown in Fig 6.

Fig 6: Lateral Ligaments

The Lateral ligaments play an important role to prevent excessive plantar flexion and inversion movements of the foot.

Along with the medial ligaments, they also provide stability to the ankle during weight bearing movements.

Medial ligaments (Inner Ankle Ligaments)

The medial ligament otherwise known as deltoid ligament is present on the inner aspect of the ankle, as shown in Fig 7.

Fig 7: Medial ligaments (Deltiod ligament)

The medial ligaments function as the main stabilizer of the inner aspect of the ankle against shear and rotational forces.

They also act to support the inner arch of the foot.

Distal tibiofibular ligaments

The distal tibiofibular ligaments are located above the ankle and connect the high ankle syndesmosis joint as shown in Fig. 8.

Fig 8. High ankle ligaments

The high ankle ligaments ensure stability between the lower end of the tibia and the fibula.

They resist any force that attempt to separate the tibia and fibula.

Risk of injury to the ankle

Any inflexibility in the ankle may cause inability to perform a movement properly. For example, poor ankle mobility due to tight soft tissue structures can reduce the range of movement at the ankle causing the knees, hips and trunk to over compensate. This may impair the ability of the trunk to load the joints properly hence increasing the risk an injury.

Like this:

The asparagus is a tall plant belonging to the lily family and is cultivated for its edible shoots. The tender young shoots of this plant are eaten as a vegetable and is well known for its health benefits. However, for some, there can be a distinct odor in their urine after consuming this vegetable.

Brief History of Asparagus cultivation

Asparagus was first known in ancient greek mythology, where the descendants of the greatest greek hero “Theseus” of Athens planted and protected asparagus by law and out of respect for the ancestors. Formal cultivation of asparagus came into being in Roman times (234-149 B.C). It became more popular in Europe, when John Gerard in 1597 called the plant “asparagi ” which he translated to signify “the first spring or sprout of every plant, especially when it be tender”.

Asparagus and Odorous Urine

The phenomenon of asparagus causing odorous urine was first documented in the 18th century. French botanist, Louis Lémery, reported a link in its ingestion causing the production of odorous urine. John Arbuthnot, a Scottish mathematician and physician to Queen Anne, noted in a book on foods first published in 1731, that asparagus affected the urine with the distinct smell (especially if eaten when they are white). French novelist, critic and essayist Marcel Proust described his experience with asparagus to be like a Shakespeare’s fairy-tale story that transforms his chamber-pot into a flask of perfume.

What causes the “Asparagus Wee Phenomenon”

With the use of soil fertilizers containing sulfur, it is believed that the sulfate components from the soil must have been absorbed by the asparagus plant. It was believed that upon digestion, this produces an odor in the urine. But why is it that other foods like garlic, parsley, cabbage and egg that contain sulfur do not create the same odor in the urine? This is as the asparagus has a unique component of sulfur that even after digestion, stays present in the urine.

Odor producing component in Asparagus

A sulfur derived asparagusic acid (1,2-dithiolane-4-carboxylic acid) is believed to be the main component that produces the odor. This acid is known to be deadly to insects and has a higher concentration in young asparagus. Through digestion, asparagusic acid is converted to methanethiol and other dimethyl components that causes the smell in wee.

Detectors and Non-detectors

The asparagus urine phenomenon does not affect all asparagus-eaters!

Research tells us that although every asparagus-eater produce smelly components in their urine, there is a variation in:

1. the amount of smelly components one produces.

2. the ability of one’s nose to detect the sense.

There is no known scientific evidence of any clinical problems associated with the production or detection of the asparagus odor.

Despite this, the asparagus has many health benefits that make it one of the most healthy vegetables.

Benefits of Eating Asparagus

Anti-inflammatory action

Asparagus contains a good amount of beacasparanin A, sarsasapogenin, protodioscin, diosgenin and many flavonoids that have been reported to reduce inflammation in the body. It will help in reducing chronic inflammation which is one of the causes for many conditions of heart, liver, joint etc.

Anti-diabetic

The extracts from asparagus have amino acid asparagine and chromium that improves insulin secretion which is responsible for glucose metabolism in the blood.

Anti-oxidant

Asparagus is rich in glutathione, a detoxifying agent that can help destroy carcinogens.

Rich source of Vitamin B

Asparagus has a rich content of B vitamins (B1, B2, B3, B5, B6, B7, B9, B12 ) that helps to turn the food we eat into energy, it metabolizes sugars and starches, decrease in fatigue. It is essential for healthy skin, hair, and nails. It helps in cell regeneration that help repair and constant renewal of the skin. Vitamin B12 helps protect against unhealthy cholesterol levels, stroke, high blood pressure and cancer.

Aid digestion

Asparagus contains a substance called “inulin” that acts as a prebiotic which is used by good bacteria to improve nutrient absorption. Also, the vegetable has a high fiber content that helps get food through the gut more smoothly. Therefore, can provide relief from digestive discomfort.

Improves brain function

The folate in asparagus works with the vitamin B12 to helps cognitive function which mean it improves the mentalprocess of knowing,includingaspectssuch as awareness,perception,reasoning,andjudgment.

Diuretic

The diuretic and alkaline properties of asparagus help flush out the kidneys and eliminate water retention in the body. It contains a substance called asparagine that makes it the remedy of choice for urinary tract problems.

Considering the health benefits of asparagus, it would be wise to ignore the odorous urine and still consume the vegetable. If the smell is an issue, try eating older asparagus instead of young shoots. Though older asparagus have a woodier stem and will need that extra bit of peeling, its sulfate content is much lower yet they have the same amount of nutrients as the younger ones.

Like this:

A ligament is a band of connective tissue composed mainly of collagen fibres. The knee joint ligaments connect the femur (thighbone) to the tibia (leg bone) at the knee joint to improve its stability and to limit the amount of mobility in the joint.

The four main ligaments of the knee joint are,

ACL: Anterior Cruciate Ligament

PCL: Posterior Cruciate Ligament

MCL: Medial Collateral Ligament

LCL: Lateral Collateral Ligament

Fig 1: Ligaments of the knee joint

Functions of the knee ligaments

Stability to the knee joint

The ligaments of the knee are responsible for preventing the tibia (shin bone) from sliding out of the femur (thigh bone). During rotational movements, knee ligaments work together to prevent both valgus (knee moved inwards) or varus (knee moved outwards) stresses to the knee.

According to their attachments in the knee, the ligaments prevent tibial displacements. For example, ACL prevents forward displacement of the tibia while PCL prevents backward displacement of the tibia. Similarily, the MCL provides support on the inner side of the knee while the LCL provides support on the outer side of the knee.

Locking the knee during walking

Apart from supporting the bones, the knee ligaments contribute to the “screw-home” mechanism, a process that locks the knees during walking. For example, just before you strike the heel to the ground your knee is slightly flexed (about 20 degrees bent) then the screw home mechanism works to straighten the knee as your body moves over the planted heel as shown in Fig 2.

Fig 2: Screw-home mechanism

What does a ligament Injury mean?

A ligamentinjury is the over-stretching or tearing of the ligaments of the knee. A tear may be partial or complete.

Fig 3 Grades of Ligament injury

What can cause a Knee Ligament Injury?

Extreme movements at the knee joint forcing the knee to move beyond its normal motion can injure a ligament. Most of the injuries occur during weight-bearing activities, as the ligaments resist against perturbations at the knee.

Types of people who usually get them

Sports people like football players, basketball players, skiers etc.

Hyper-mobile individuals who engage in high-impact sports may have an injury due to excessive laxity in the knee ligaments.

Accidental fall on the knees or hit on the knees during contact sports like rugby, football etc or automobile accidents (in which the knees can hit the dashboard)

Mechanism of an injury

Fig 4: Causes of knee injury

Hyper extension injury

Extending the knee too far by over straightening of the knee. This can happen when you stop suddenly while running.

Flexion and Hyperflexion injury

Jumping and landing on a flexed (bent) knee or falling on your knees with over overbent knees.

Rotational injuries

Valgum (inner) or varum (outer) stress on the knees due to twisting of your knee inwards and outwards. Sudden shifting of weight from one leg to the other.

Contact Sports

Accidental hit on the knee during sports as shown in Fig 5

Fig 5: Direct hit on the leg

Other Reasons that contribute to a Ligament Injury

Lack of force distribution

During movement, the body exerts a force on the ground and at the same time, an equal and opposite ground reaction force (GRF) is exerted by the ground on the body. This GRF is directed towards the center of mass (COM) of the body, a point in the body where the entire body weight is concentrated; in front of the tailbone.

If there is an imbalance, which means the athlete’s knee does not bend on landing and remains straight, the GRF creates a forward shear force that pushes the tibial forwards, stressing the ligaments. Hamstring muscles on the back of the thigh play a vital role in stabilizing the knee joint especially when the athlete lands. Normally, the knees normally bend slightly to absorb GRF as shown in Fig 6.

Fig 6: Hamstring action advantage for absorbing GRF

Lack of trunk control

Without trunk control, there will be greater movements in the trunk following a perturbation (disturbance) which could affect the distribution of the GRF.

Lack of control in the trunk motion happens because of diminished proprioception. In such a situation, if the trunk moves more on the side of the knee joint laterally, the GRF tracks the COG and follows the movement of the trunk. As the GRF tracks the COM, and if it progresses beyond the center of the knee joint, it results in a movement of the knee joint into a valgus alignment stressing the knee ligaments as shown in Fig 6.

Fig 6: Valgus alignment of the left knee

Signs and Symptoms of Ligament Injury

Popping sound at the time of injury can indicate a ligament rupture.

The knee swelling within the first 24 to 48 hours

Tenderness and possibly redness around your knee on touching.

Knee feels unstable or may buckle during weight bearing. This may cause you to limp or feel wobbly at the knee during walking.

Bruising around the knee can develop.

What to do if you think you have an injury?

If you are having any of the above signs or symptoms, seek immediate medical attention. What can appear to be a simple ligament or soft tissue strain may become something more if left untreated. Diagnostic tests such as an X-ray or MRI scan will be able to show any tears or rupture of the ligaments. According to the severity of the ligament injury, appropriate treatment care will be advised.

The temporomandibular joint (TMJ) or the jaw joint is a synovial hinge type of joint. This joint is responsible for the movements of our mouth that are needed for chewing, biting, talking and yawning.

To achieve the complex movements needed by the jaw, the TMJ has two articulating surfaces which include the head of the mandible (jaw bone) that fits in the articulating socket of the temporal bone of the skull. In order to prevent friction between the two bones, an articular disc sits between the articulating surfaces which moves with the head of the mandible as one unit.

Fig 1: Normal TMJ when jaw closed

Apart from the disc and articulating structures, there are other supporting structures that provide stability to the TMJ:

Joint Capsule

Ligaments

Muscles

Joint capsule and Ligaments of the TMJ

The capsule is a fibrous cartilaginous membrane that along with the ligaments surrounds the TMJ and attaches all around the articular eminence of the temporal bone, the articular disc and the neck of the mandibular condyle. Both the capsule and the ligaments provide stability to the TMJ during movements. The four ligaments include (Refer Fig 2),

Individuals who have misaligned jaw or teeth which are hereditary can be affected with TMJ disorder.

Functional mandibular overload

Normally the jaw is free to move and make contact with the teeth in the right position, (centered occlusion), in anatomical and functional harmony.

Mandibular overload occurs when one sleeps in a wrong position (face down) where the load of the head pushes the mandible to compress the TMJ on one side and attenuation of the ligaments on the other side. Compression obstructs the blood circulation and moves the teeth to a lateral bad occlusion position. In such a situation, swallowing causes the masticatory muscles to overwork to centre the jaw and bring the teeth from forced lateral malocclusion to centred occlusion. This causes a disharmony between the upper and lower teeth. An imbalance of the jaw that can cause bruxism in an attempt to re-position the teeth.

The term bruxism is defined as an involuntary rhythmic or spasmodic non-functional gnashing, grinding or clenching of teeth. The rubbing causes tooth facet to wear out, structural and function damage to the capsulo-ligamentous and muscles around the TMJ. Stress and psychological problems could worsen the condition.

Sudden trauma

Whiplash injury occurs any time when the head is suddenly and unexpectedly distorted from the neck, causing overstretching of the muscles and ligaments that hold the neck and head in alignment. During a whiplash injury, there is also a potential secondary injury of whiplash in the jaw. Jaw dislocation in severe cases can also occur.

Inflammatory diseases

Sometimes infection in the teeth or adjacent structures can cause a spread of infection in the TMJ leading to infectious arthritis.

TMJ could also be affected by osteoarthritis that causes damage in the articular cartilage of the joint and disc degeneration leading to friction between the bones causing inflammation and pain. It usually affects individuals above 50 years of age and is associated with trauma and other muscular and teeth problems.

TMJ disorder could also be present among individuals who are already diagnosed of rheumatic arthritic disease.

Symptoms of TMJ

Jaw pain: Pain and tenderness in the jaws. Increasing pain during chewing in the TMJ and in the muscles, radiating pain is also felt in the face, jaw, or neck.

Limited or painful jaw movement: Swelling due to the inflammation lead to joint stiffness and limited movement, wear and tear of the disc leading to locking of the jaw and impaired jaw function.

Headache, Neck pain or stiffness: It is generally assumed that headache, neck pain, or painful jaw movement is suggestive of muscular problems. Masticatory and neck muscles may show muscle spasm and myofascial trigger points in the masseter or sternocleidomastoid muscles that refer pain to the head.

Clicking or popping: This occurs within the joint during mouth opening and may indicate displacement of the intra-articular disk during mandibular movement.

Ear pain and tinnitus (Ringing of the ear): Middle ear muscles have a common embryological and functional origin with masticatory (Chewing muscles) and facial muscles.Having said that, problems with muscles in TMJ disorder could affect the middle ear. In case, other ear problems are not the cause of ear pain and tinnitus a temporomandibular joint dysfunction may be the reason of these symptoms.

Prevention and Treatment

In order to relieve pain and restore the function of the TMJ, a thorough assessment is required to correctly determine the causative factors and to treat the involved structures. Personalized care interventions at an early stage that includes behavioural change and reassurance are important steps for prevention of TMJ disorder.

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